Overview
• Anatomy
• General Concepts
• Causes
• Treatment Options
• Static
• Dynamic
• Management of the…
• Brow
• Eyelids
• Mid-Lower Face
• Rehab
• Complications and Management of Synkinesis
• Future Direction and Research
General Concepts
• Multiple etiologies
• Diverse presentation
• Not life threatening
• Severe QOL implications and psychological impact
• Prognosis and outcomes variable
Etiology
• Idiopathic
• Infection
• Trauma
• Iatrogenic
• Metabolic
• Toxic
• Vascular
• Neurologic
• Otologic
• Congenital
Treatment Options
• Observation
• Conservative
• Prednisone: 1mg/kg per day for 7-10 days with slow taper
• Acyclovir/Valcyclovir
• Chemodenervation, Fillers
• Direct Nerve Repair and Cable Grafting
• Static Procedures
• Facial Sling, Gold Weight
• Dynamic Procedures
• Nerve, muscle or free tissue transfer
Timing and Considerations with Facial Paralysis
• Patient Age
• Onset
• Immediate
• Delayed
• Duration
• Involved Branches
• Progression
• Complete
• Incomplete
• Patient Expectation
• Status of the Eye
Primary Nerve Repair and Cable Grafting
• Ideal for injuries < 72 hours
• Best functional outcomes
• Epineural vs Perineural repair
• Tension free closure
Cable Grafting
• Great Auricular Nerve • 7-10cm
• Close proximity
• Sural Nerve • 30-75 cm
• Several branch points for multiple anastomoses
• Medial and Lateral
Antebrachial Cutaneous Nerve • Good for concomitant RFFF
• ~20 cm harvest
Cable Grafting Pearls
• Oblique cut to facilitate grafting more then one branch
• Harvest ~25% > defect length
• Graft zygomatic and mandibular branches first
• At least 6 months for recovery but can be up to 1-2 years
• Often times perform static procedures concomitantly
Neural Conduits
• End to end anastomosis not
possible
• Good for gaps < 3cm
• Provides support, shape and
guidance for axonal regeneration
• Limits fibrosis, neuroma
formation and FB reaction
• No donor site morbidity
Nerve Conduits
Nerve Transfer
• Keys to success: Strong contraction, harvest should not result in
serious deficit, ability to adhere to rigid rehab program
1879: Earliest description of nerve transfer by Drobnick, CN XI->VII
1901: Korte performed first CN XII -> VII transfer
1924: Balance recurrent laryngeal -> VII transfer
1971: Scaramella and Smith reported cross
facial nerve grafting
1984: Terzis introduced the
“babysitter” procedure which
combined CFNG and partial XII-VII
transfer
Cross Facial Nerve Grafting
• Contralateral CN VII ideal
• <6 months denervation if used as sole
procedure
• Work medially to laterally to find
branches
• Map out branches
• Ideally match like to like
• Make tunnels prior to neurorraphy
• Sural Nerve most common
• Disadvantages: donor site deficits, long
interval of reinnervation, limited donor
axons, two coaptation sites, possible
sacrifice of function
Nerve Transfer Options
• XII -> VII transfer • Sacrifices ipsilateral XII
• Hemiglossal dysfunction, lingual atrophy
• End to side, end to end, interposition graft, partial transfer
• Babysitter procedure • Partial CN XII transfer with CFNG
• Gives immediate motor function while waiting for CFNG reinnervation without ipsilateral tongue paresis
Nerve Transfer Options cont.
• CN V transfer
• CN XI transfer
• Last resort, Mobius syndrome
• Less natural result and severe
donor site morbidity
• Cervical Roots
Static Procedures
• Good for temporary paralysis, poor candidates for dynamic
procedures, atrophied muscles, failed dynamic procedure
• Facial Slings, Gold weight, Lower lid tightening
Static Treatment of the Eyelid
• Orbicularis Oculi main depressor of upper lid
• Used to treat exposure keratitis
• Tarsorrhaphy
• Lid Loading (Gold vs Platinum weight)
• Lateral Tarsal Strip
• Medial/Lateral Canthopexy
Static Treatment of the Brow
• Browlift
• Direct
• Midforehead
• Coronal
• Trichophytic
• Endoscopic
Static Treatment of the Lower Face –
Facial Slings
Material Advantages Disadvantages
Fascia Ease of harvest, autologous Donor site morbidity,
tendency of tissue to
stretch
Lyophilized dermis
(AlloDerm, ENDURAGen)
No donor site,
incorporation into recipient
tissue
Unpredictable
stretching/elongation
Expanded
Polytetrafluoroethylne
(e-PTFE)
Technically easy, local
anesthesia, no donor site,
ease of revision/reversal
Higher infection and
extrusion rates
Multi-vector suture
suspension
Least invasive, local
anesthesia, quick healing,
easy revision
Unpredictable stretch and
relaxation, suture breakage
Dynamic Muscle Transfer
• Restore oral competence
• Most commonly used for long standing facial paralysis,
restoration of neural input not feasible
• Uses functional, innervated and vascular muscle
• 2 options
• Regional muscle transposition
• Free muscle transfer
• First description in 1911 by Eden, later
popularized in 1977 by Rubin
• Most commonly used muscles
temporalis, masseter and digastric
• Temporalis Muscle Transfer
• Innervated by V3, Blood supply deep
temporal artery
• “Temporal Smile”
• Donor site depression, bulge over
zygoma, revision surgery, lack of
orthodromic muscle contraction
Regional Muscle Transposition
Temporalis Tendon Transfer
• Popularized by Labbe
• Coronal and nasolabial incisions
• Slight overcorrection
• Orthodromic muscle contraction, natural vector of
pull, less bulky, no donor site depression
• 2 versions of technique
Masseter and Digastric Transfer
• Masseter
• Melolabial incision
• Less excursion then temporalis
• Digastric
• Injury to the marginal branch -> paralysis of the depressor anguli oris
and depressor labii inferioris
• Anterior belly of digastric
• Submental incision
Free Tissue Transfer
• Offers possibility of synchronous, mimetic movement
• Muscle alone and muscle + soft tissue
• Gracilis is first choice and most popular
• Located medially and posteriorly to the adductor longus
• Attaches to pubic symphysis and medial aspect of tibia
• Medial femoral circumflex or profunda femoral artery
• Pedicle length ~ 6-8 cm
• Anterior branch of obturator nerve
Gracilis Free Tissue Transfer
• 2 stage procedure
• CFNG
• Gracilis FFMT
• 1 stage procedure
• Masseter nerve
• Facial vessels as recipient site
• 1cm and 2cm additional length to avoid
lip contracture deformity
• Early training and muscle stimulation
• Complications
• Hemorrhage, injury to Stenson’s duct,
flap failure, lip contracture, bulkiness,
lip asymmetry
Facial Rehab
• Nonspecific light massage, electrical stimulation, and
repetitions of common facial expressions in a general
exercise regimen
• Facial Neuromuscular re-education
• Enhance desired muscle activity
while reducing others
• Surface EMG biofeedback and
mirror feedback
• How to measure success?
• Facial Grading System
• Facial Disability Index
Management of Synkinesis
• Abnormal involuntary movement
that occurs simultaneously during
voluntary muscle contraction
• Aberrant nerve regeneration
• Sunderland Class III and above
• ~20% patients
• Treatments include facial
neuromuscular retraining, Botox
injection, selective neurolysis or
myomectomy
Facial Analysis
• Recently, computer analysis has been used to quantitatively measure facial asymmetry and thus synkinesis
• Increased sensitivity and reliability
• Facial Assessment by Computer Evaluation (FACE)
• Peak Motus Motion Measurement System
• Automated Facial Image Analysis (AFA)
• New focus on 3D analysis
Conclusion
• Many options to treat facial paralysis from neurorraphy to
free muscle transfer
• Onset, timing and duration of paralysis is important
• Must match goals of the patient with goals of surgeon
• New and dynamic field of facial plastic surgery with
continual advancements which will allow for objective data
and better results
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